Introduction
As the “Integrated Model of Problem Gambling” points out (Blaszczynski, 1998), a variety of gamblers arrive at the common pathway of problem gambling as a result of wide-ranging, intersecting biological, psychological and sociological factors. In this chapter, we will look at how psychiatric disorders intersect with problem gambling and discuss some treatment strategies. It is crucial that clinicians know the limits to their knowledge and skills, their professional role, and their legal responsibilities in dealing with clients.
Relationship between Problem Gambling and Psychiatric Disorders
In this chapter, the term “problem gambling "will refer to a broader range of individuals who experience negative consequences as a result of their gambling (see Section Definitions and Prevalence of Gambling and Problem Gambling, for a definitional outline). With the high general prevalence, it is not surprising that many problem gamblers also suffer from other psychiatric disorders. For example, a major nationwide U.S study showed clearly that problem gamblers have significantly higher psychiatric concurrent disorders than non-gamblers and recreational gamblers:
Other similar studies have found a high rate of psychiatric disorders in gamblers who sought treatment for their problem gambling: the vast majority (92%) of whom had a lifetime prevalence (54% occurred at the time of treatment) of a major psychiatric disorder, and 25% of whom had a personality disorder (Specker et al., 1996). No research clearly shows the prevalence of psychiatric disorders according to the organization of our “pathway” approach; however, one would suspect pathways 2 and 3 problem gamblers may have more psychiatric problems because of common environmental and neurobiological links with other psychiatric disorders.
Some possible theories
While a well-developed theory to explain the nature of problem gambling is not available, the “self-medicating” hypothesis provides some physiological insight. This theory explains that human beings strive to maintain a balanced state of contentedness, free from anxiety, fear, or sadness. When there is a disturbance to the balance, through genetic or environmental factors, we attempt to regain the balance through whatever means available to us. At a neurochemical level, this balance is best known to be related to levels of the identifiable neurotransmitter dopamine. Common substances such as alcohol, nicotine, cocaine, etc., are known to increase the levels of dopamine, however transiently, thus restoring the sense of well-being. This explains why some individuals are more susceptible to being addicted to these substances. Recent studies have also found that gambling can increase the levels of dopamine, providing the link to a form of substanceless addiction.
Research has also linked a high level of impulsivity and compulsivity to a disturbance in the neurotransmitter serotonin. Correspondingly, many problem gamblers have difficulty controlling their impulsivity and compulsion, and recent research has shown that some of these gamblers indeed have a serotonin deficiency. The serotonin theory thus provides some insight into the nature of problem gambling as an impulsivity and compulsion problem.
Of course, a neurochemical and medicalized explanation of gambling problems is a gross oversimplification of the issue, and pathway 1 clients are unlikely to have many addiction, impulsivity or compulsion problems — their problem may be mostly environmental and circumstantial. Nevertheless, knowing the common neurochemical links does help us understand the relationship between problem gambling and other psychiatric disorders for pathway 2 and 3 clients. For example, a low level of serotonin is highly associated with major depression, attention deficits and anxiety disorders — perhaps those pathway 2 and 3 clients are more likely to have concurrent psychiatric disorders because of this shared neurochemical vulnerability.
The Concurrent Psychiatric Disorders
Given that some of the pathway 1, and mostly the pathway 2 and 3 clients will have a concurrent psychiatric disorder, I will review some of the more common and significant psychiatric disorders known to be associated with problem gambling: depression, anxiety, adhd, antisocial personality, psychotic disorder and suicide as a special issue. I will provide a brief description, some relevant key research findings, and some pragmatic information such as ways to screen for psychiatric problems, when to refer clients to other professionals, and how to work with psychiatrists, etc. For a few disorders, I have included a brief case illustration as well (these cases are based on clinical material, but identifying data, including clinical details, have been altered to protect confidentiality).
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